HERNANDEZ LAW GROUP INC. NEW CLIENT BANKRUPTCY INFORMATION PACKET Putting together a bankruptcy case is a detailed process requiring information about the property you own and the debts you have. The attached questionnaire is designed for both Chapter 7 and 13 bankruptcy clients to make sure that your financial situation can be evaluated thoroughly by your attorney and reported accurately to the court. Please fill out the questionnaire truthfully and to the best of your ability. Leave blank any sections that you feel are inapplicable to you. If you are not sure about your responses to a question, the attorney can assist you in answering it at your next appointment. CREDIT COUNSELING: Prior to filing a bankruptcy all filers must take the court-mandated credit counseling course. You may use any approved counseling provider, though if you enter our firm code with the providers listed below, your certificate of completion will automatically be sent to this office: Cricket Credit Counseling Firm Code:258870 Online Only: www.cricketdebt.com Cost $36 for singles or joint
CC Advising No Firm Code Needed Only Offer First Course Online Only www.ccadvising.com Cost $14 per person 1st Choice Credit Counseling FIRM CODE 1st Course : 9215URAQ FIRM CODE 2nd Course : 8816CBZC Online: www.mybknow.com Phone: 877-692-5669 Cost $25 for first course Cost $12 for second course
Solid Start Financial Firm Code 258870 Second Course Only Online:www.Solidstartfinancial.com Phone 866-467-4147 Cost $24 per household Access Counseling INC. FIRM CODE: HL21487 Online: accesshope.net Phone: 800-788-7857 Cost: $25 for each course Course is also in Spanish Green Path Debt Solutions FIRM CODE: Hernandez Online: GreenPathBK.org Phone : 866-332-8434 www.greenPathBK.org Cost:1st Course $25 Cost 2nd Course $15
ADDITIONAL DOCUMENTS: In addition to filling in the questionnaire, all clients must provide this office copies of the following documents Copy of last 2 years most recent filed tax returns, including w2 forms Last 6 months of wage stubs for each party (*includes both spouses’ wage stubs regardless if one spouse is not filing) Last 6 month Profit and Loss Statement (by individual month) for self-employed clients Last 6 months of bank statements for all accounts 1
List of your Creditors (See Section 3 below) Deed to each piece of Real Property you own Copy of most recent mortgage statement (all mortgages) Copy of most recent auto loan statement (all auto loans) Copy of most recent life insurance policy statement, if applicable Copy of any lawsuit you have been a party to within the past 1 year
CONTACT INFO: Once you have completed the questionnaire, you can remit the completed questionnaire to our office by mail, fax or e-mail and contact us to set up an appointment with the attorney, if one has not been scheduled already. Hernandez Law Group www.khlawoffices.com Sacramento: 7777 Greenback Lane, Suite 212 Citrus Heights, CA 95610 Ph:(916) 728-1500 Fax: (916) 728-1515
Bay Area: 37600 Central Court, Suite 201 Newark, CA 94560 Ph:(510) 456-7400 Fax:(510) 456-7411
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Section 1 Basic Information Part A. Name and Address Name: Last
First
Middle
First
Middle
DOB:____________
Spouse Name: Last Spouse DOB:______________
Telephone Number Home: _________________________ Cell: ________________________________ Have you used any other names in the past eight years? No
Yes
If yes, list other names:
Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Spouse Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Address:
__________________________________________________________________________
City:
_______________________ State: __________ Zip: _______________________________
County:
_____________________
Have you lived at this address for at least 180 days? No Yes Have you lived at this address for at least 3 years? No Yes If you answered no to either of the questions above, please list your previous address: Address: ______________________________________________________________________ City: _____________________ __________ State: _______________________ Zip: County: ________________
Dates of occupancy: ______________________
If you have a different mailing address, please list: Mailing Address: _____________________________________________________________________ City:
_______________________ State: __________ Zip: _______________________________
If your spouse maintains a separate address, please list: Spouse Mailing Address: ______________________________________________________________ City:
_______________________ State: __________ Zip: _______________________________
Part B. Prior/Pending Bankruptcy Cases Has a bankruptcy case been filed by you or against you in the last 8 years? No
Yes
If yes, in which district of which state was the case filed? _____________________________________ Case Number: _____________________ Date filed: ________________________________________ Are there currently any bankruptcy cases pending against you, your business, your spouse, or your spouse’s business? No Yes If yes, name of debtor: ____________________________ Relationship to you: __________________ Case Number: ________________ Date filed: ____________ Judge:
________________________
In which district of which state was the case filed?
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Section 2 Property Part A. Real Estate List all real estate (including timeshares) which you own or are a joint owner of, even if you still owe money on the property. Address of property
Value
List all mortgages, home equity loans, and liens
If you rent, provide the name and address of your landlord:_________________________________________ ________________________________________________________________________________________
Part B. Personal Property List all vehicles you own or are a joint owner of, even if you still owe money on the vehicle. Include cars, trucks, boats, etc. Vehicle Year, Make and Model
Condition
Lender Name
List all bank accounts (checking, savings) you own or are a co-signer on. Bank Account Type of Account
Mileage
Keep or Surrender?
Amount
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Cash on hand. State the amount of cash you currently have other than monies in bank accounts. $____________. This figure will be updated to reflect what you have on the date of filing. Security Deposits with Public Utilities, Telephone Companies, Landlords and Others. Do you have any security deposits? ____Yes ____No. If yes, identify the name of the entity holding the deposit, the amount, and whether it’s a lease or month-tomonth tenancy. _______________________________________________________________________ _______________________________________________________________________ NOTE: VALUING PERSONAL PROPERTY: When you answer questions, 3-7, give your best estimate of the current value of the property, not the price you paid. Use the value you think a stranger would pay you for each item if you sold it at a garage sale, or ebay. Please state “None” if you have no property described by the sub-category. If you have some property, but it is of little or no value, you must give a dollar amount, even if it is $1.00. 1. Household Goods and Furnishings, Including Audio, Video, and Computer Equipment. Bedroom Furniture___________________ sewing machine__________________ Living room furniture___________________ satellite dish____________________ Family room furniture__________________ patio furniture___________________ Dining room furniture__________________ barbeque_______________________ Refrigerator__________________________ gardening equipment______________ Kitchen appliances (non-“built-in”)_________ tools___________________________ Kitchen table & chairs__________________ pool table_______________________ Kitchen equipment (i.e. pots, pans, dishes, piano/organ_____________________ flatware utensils, glasses)_______________ computer equipment (not for business) china___________ silver________________ ____________________________ TV(s)________________ how many? ______ luggage________________________ VCR(s)_______________ how many?______ linens, bedding, towels_____________ Video games & player___________________ stereo equipment_________________ Vacuum cleaner________________________ children’s toys____________________ Washer____________ Dryer______________ Other___________________________ Please list any single item in any category above that is clearly worth more than $550 at a garage sale or auction by describing the item and its value below: _____________________________________________________________________________ _____________________________________________________________________________ 2. Books, Pictures, and Other Art Objects, Antiques, Stamp, Coin, Record, Tape, Compact Disc and Other Collections or Collectibles. List the value on the blank space to the right of each sub-category where applicable. Books_______________ Records______________ DVDs________________
computer discs_____________________ pictures___________________________ original paintings____________________ 5
Video Tapes___________ if so, how many?_________________ Stamp Collection______________ coin collection______________________ Antiques, other art objects, other collections—identify and state value ____________________________________________________________________________ 3. Wearing Apparel. List the value of all clothes and footwear._______________________ 4. Furs & Jewelry. List the value on the blank space to the right of each sub-category where applicable. Furs___________________ wedding rings______________________ Watches___________ how many?________ all other jewelry ____________________ If any piece of jewelry is worth $1,000 or more, please describe the item and its value: _____________________________________________________________________________ 5. Firearms & Sports, Photographic and Other Hobby Equipment. List the value of each hand gun(s)_______________ how many?______ bicycle(s)____________ how many?____ rifle(s)___________________ how many? ______ exercise equipment__________________ camera(s) __________ make, model __________ camping equipment__________________ sports equipment (golf, tennis, skiing, fishing) musical instrument(s)________________ ________________________________________ other_____________________________ 6. Insurance Policies. Name on insurance company of each policy and itemize surrender or refund value of each policy. Do you have any life insurance policies? Yes____ No_____ Is it a term policy (one that only pays if you pass away) or a whole life policy (one that returns cash to you if you cancel the policy)?_________ If whole life, state the cash surrender value and the date that you have confirmed it with your agent or the insurance company. $_____________ Name of Insurance Company__________________________ Do you have a disability insurance policy? If yes, name the insurance company_____________ If there is any other policy in your name, please provide a separate sheet with an explanation. 7. Annuities. Itemize and name each issuer. Do you have any annuities other than your retirement plan? Yes______ No______ If yes: Name & address of annuity company________________________________________ Current cash surrender value____________________________________________________ Describe when you can withdraw the funds and in what amounts _________________________________________________________________________ Please bring a copy of the contract. 8. Interest in an Education IRA or Under a State Qualified Tuition Plan. Do you have any such plans? Yes_______ No_______ If yes, please provide particulars and all records. _____________________________________________________________________________ _____________________________________________________________________________ 9. Interests in IRA, ERISA, Keogh, or other Pension or Profit Sharing Plan (Including Retirement, Employee Stock Ownership and Deferred Compensation Plans). Do you have any such plan? Yes_____ No_____ If yes, please provide the most recent statement from each account. 6
10. Interests in Partnerships or Joint Ventures. Do you have any interest in any partnership or joint ventures? Yes _____ No ______ If yes, complete Section 7. 11. Government and Corporate Bonds (including Savings Bonds). Do you have any bonds or financial instruments? Yes______ No_______ 12. Accounts Receivable. If you are operating, or have operated, a business, do you have any money owed for goods sold or services provided, even if not yet billed? Yes____ No_____ 13. Alimony, Maintenance, Support, and Property Settlement. Have you ever been divorced? Yes_____ No_____ If yes, please bring us a copy of any Court orders finalizing your divorce and the division and distribution of all property between parties. Are you in a divorce proceeding that is not final? Yes ______ No ______ Filing date: ________ If yes, please bring us a copy of any temporary orders and the latest proposed property settlement agreement, if any. Identify the name and address of any spouse or ex-spouse who is delinquent on support payments to you. _____________________________________________________________ 14. Other Liquidated Debts Owed to Debtor (including Tax Refunds). Does any person or entity owe you money for any reason other than accounts receivable? Yes _____ No _____ If yes, state the name & address of the person/entity, reason, and amount. Include any tax refund not yet received where the return has already been filed. If you are paid on a commission basis, confirm the amount of earned, but unpaid commissions. _____________________________________________________________________________ _____________________________________________________________________________ 15. Machinery, Fixtures, Equipment and Supplies used in Business. Describe: _____________________________________________________________________________ _____________________________________________________________________________ 16. Animals. Do you have any pets? Yes ____ No ____ 17. Other Personal Property of Any Kind Not Already Listed. _____________________________________________________________________________ _____________________________________________________________________________ Do you have any accrued vacation credits from your employment that you can cash in? Yes___ No___ If yes, what is the current cash in value? ______________________________ Do you receive Social Security, general assistance, AFDC, or unemployment benefits? Yes___ No___ If yes, identify the source, when benefits are paid, and how much you receive. _____________________________________________________________________________ _____________________________________________________________________________
Section 3 Debts This office needs information on all debts that you owe. Please provide a copy of a bill for every debt that is owed. If you do not have a bill, please make a list of the creditor’s name, address, amount owed, and account number so that we can include the debt in your case.
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Section 4 Current Income Provide this office with copies of your last 6 months wage stubs. Marital Status: Married Single Divorced Separated Widowed
List all dependents of you and your spouse, their ages, and their relationship to you:
Name
Age
Relationship
How many people live in your home? ________ (*Include those living with you part time)
Part A. Debtor’s Income
Part B. Joint Debtor’s Income
1. What is your occupation? ________________
1. What is your spouse’s occupation?______________
2. Name and address of your employer:
2. Name and address of your spouse’s employer:
_______________________________________
_____________________________________
_______________________________________
_____________________________________
_______________________________________
_____________________________________
3. How long have you been employed there?_____
3. How long employed there? _________________
4. How often are you paid? __monthly __twice/month ___ every other week ___ weekly __ other
4. How often are you paid? __monthly __twice/month ___ every other week ___ weekly __ other
5. Gross income paid per pay period? $_________
5. Gross income paid per pay period? $_________
Complete the below questions with your estimate of monthly averages.
Complete the below questions with your estimate of monthly averages.
Do you receive a) income from business operations outside of your regular paycheck listed above? If so, what is the business and how much do you receive per month?
Does your spouse receive a) income from business operations outside of the regular paycheck listed above? If so, what is the business and how much does your spouse receive per month?
b) income from real estate property? If so, how much per month? No Yes $_________
b) income from real estate property? If so, how much per month? No Yes $________
c) alimony or family support payments for your use or for the care of your dependents? If so, how much per month? No Yes $_________
c) alimony or family support payments for spouse’s use or for care of dependents? If so, how much per month? No Yes $_______
d) social security or other forms of monetary government assistance? No Yes $______
d) social security or other forms of monetary government assistance? No Yes $_______
e) retirement or pension money? No Yes$____
e) retirement or pension money? No Yes$____
Do you have any other sources of income not listed?
Does your spouse have any other income not listed?
Are you or your spouse expecting any increase or decrease in salary next year? If so, explain.
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Section 5 Current Expenses Do you and your spouse maintain separate households? No Yes. If so, fill one page out for your household and another for your spouse’s. The following questions ask for your expenses each month. If you are unsure of the amount you pay each month, but know the amount for a different period (per week, per day, every 2 months, etc.,), write in the amount and the frequency that you pay the amount.
Indicate how much you pay for each item each month… st
1. your rent or your home mortgage Does that amount include real estate taxes? No Yes Does it include property insurance? No Yes
$1 /rent___________ nd $2 _______________
2. electricity and heating
$_________________
3. water and sewage
$_________________
4. telephone service/long distance
$_________________
5. Do you have any other utility bills (cable, internet, garbage)? If so, what, and how much per month? __________________________________________________
$_________________
_________________________________________________
$_________________
__________________________________________________
$_________________
6. home maintenance, including repairs and general upkeep
$_________________
7. food
$_________________
8. clothing
$_________________
9. laundry and dry cleaning
$_________________
10. medical and dental expenses (not covered by insurance)
$_________________
11. transportation (not including car payments)
$_________________
12. entertainment, recreation, newspapers, magazines
$_________________
13. charitable contributions
$_________________
14. insurance not deducted from paycheck a) homeowner’s or renter’s insurance b) life insurance c) health insurance d) auto insurance e) other insurance_______________________
$_________________ $_________________ $_________________ $_________________ $_________________
15. taxes not deducted from paycheck (i.e. property tax, self-employed tax)$_________________ 16. installment payments for car, furniture, etc. (Specify) __________________________________________________
$_________________
_________________________________________________
$_________________
__________________________________________________
$_________________
17. alimony, child support, maintenance, support paid to others
$_________________
18. payments for support of dependents not living at home
$_________________
19. expenses from operation of business
$_________________
20. court ordered payments not already listed ___________________
$_________________
_________________________________________________
$_________________
21. education necessary to maintain employment
$_________________
22. education for a physically or mentally challenged child
$_________________
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23. childcare
$_________________
24. care for elderly, chronically ill, or disabled family members
$_________________
25. education expense for your children under 18
$_________________
26. public transportation expense to/from work
$_________________
28. public transportation expense for children to/from school
$_________________
27. other expenses not listed above __________________________
$_________________
_________________________________________________
$_________________
_________________________________________________
$_________________
_________________________________________________
$_________________
Section 6 Financial History If you are filing jointly with your spouse, include information about both you and your spouse. If you have no information to report for a question, check the "NONE" box. 1. Payments of Cash or Transfers of Property to Family and Friends In the last one year, have you made a payment or transferred any item of property to a family member or friend? If yes, please explain below. If you have not, check this box: NONE
2. Income other than from employment or operation of business State the amount of income received other than from employment or operation of business during the two years immediately preceding the commencement of this case (i.e. gambling winnings, unemployment): NONE Period
$ Amount
Source
Husband/Wife
3. Payments to creditors List all payments on loans, installment purchases of goods or services, and other debts, adding up to more than $600 to any one creditor made within 90 days immediately preceding the commencement of this case. NONE Name and Address of Creditor
Dates of Payments
Amount paid
Amount still owed
4. Suits, executions, garnishments and attachments a. List all suits and administrative proceedings to which you are or were a party within one year preceding the filing of this case. NONE Caption of Suit and Case Number
Nature of Proceeding
Court or Agency and Location
Status or Disposition
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b. Describe all property that has been garnished, seized, or attached under any legal or equitable process within one year immediately preceding the commencement of this case. NONE Name and Address of Person/Company for Whom the Property Was Seized (Creditor)
Description and Value of Property
Date of Seizure
5. Repossessions, foreclosures, and returns List all property that has been repossessed by a creditor, sold at a foreclosure sale, transferred through a deed in lieu of foreclosure, or returned to the seller, within one year immediately preceding the commencement of this case. NONE Date of Repossession, Foreclosure, Transfer or Return
Name and Address of Creditor
Description and Value of Property
6. Gifts List all gifts or charitable contributions made within one year immediately preceding the commencement of this case except ordinary and usual gifts to family members aggregating less than $200 in value per individual family member and charitable contributions aggregating less than $100 per recipient. NONE Name and Address of Recipient
Relationship to You, if Any
Date of Gift
Description and Value of Gift
7. Losses List all losses from fire, theft, gambling or other casualty within one year immediately preceding the commencement of this case or since the commencement of this case. NONE Description and Value of Property
Description of Circumstances and Amount Covered by Insurance, if Any
Date of Loss
8. Other transfers (including sale of your property) a. List all other property, other than property transferred in your ordinary course of business or financial affairs, transferred either absolutely or as a security within two years immediately preceding the commencement of this case. NONE Name and Address of Transferee and Relationship to you
Date of Transfer
Description of Property Transferred and Value Received
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9. Closed financial accounts List all financial accounts and instruments held in your name or for your benefit which were closed, sold, or otherwise transferred within one year immediately preceding the commencement of this case. NONE Name and Address of Institution
Type and Number of Account & Final Balance
Amount and Date of Sale or Closing
10. Safe deposit boxes List each safe deposit or other box or depository in which you have or have had securities, cash, or other valuables within one year immediately preceding commencement of this case. NONE Name and Address of Bank or Other Depository
Name and Address of Those With Access to Box or Depository
Description of Contents
Date of Transfer, if Any
11. Spouses and Former Spouses If you were married to anyone other than your current spouse in the last eight-year period, identify the name of your former spouse. NONE
Name:_________________
Section 7 Business Owners Have You Owned a Business in the last 6 Years?
NONE
If yes, please provide the following information for each business you have owned (Attach separate pages, if needed):
A. Business Name
B. Business Address
C. Date Business Began Operating and Stopped Operating (if Closed)
D. Name and address of Business Bookkeeper
E. Name and address of Business Tax Preparer
F. Name of all Partners or Shareholders of Business and percentage owned by each
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G. If the business is a sole proprietorship, please provide a list of the business assets and the value of these assets.
H. If the business is a sole proprietorship, please provide a list of the business inventory and the value of this inventory. I.
If you still own the business, please estimate the amount of the fair market value of the business is (if anything) if you were to try and sell it.
Section 8 Secured Debts When your agreement with a creditor allows the creditor to take certain property from you if you do not pay, the debt is “secured” by the property, which is called “collateral.” Below is a list of common Secured Creditors. Please indicate if you owe any debts to the following creditors:
Best Buy……………………………………………………___Yes ___No
Kay Jewelers……………………………………………….___Yes ___No
Ashley Furniture…………………………………………..___Yes ___No
Busy Body Home Fitness………………………………….___Yes ___No
RC Willie…………………………………………………...___Yes ___No
Ford Motor Credit…………………………………………___Yes ___No
Any other Debts you know to be a Secured Debt………..___Yes ___No
*If you checked “yes” to any of the above debts, you may be required to complete a Reaffirmation Agreement to keep the collateral after your case is filed. Please see the “Reaffirmation Agreements: What Is It and Do I Need to Enter Into One?” Disclosure provided in the Information Folder provided to you at your consultation.
Section 9 Tax Debt Do you owe debt to the IRS?
___Yes ___No
If Yes, what tax year is the debt from? _______________________ *How much do you owe in total?_____________________________
Do you owe debt to the State Franchise Tax Board?
___Yes ___No
If Yes, what tax year is the debt from? _______________________ *How much do you owe in total?_____________________________ *It is very important that we have the exact amount you owe to each tax agency before we file your case. If you are unsure of the amount owed and/or tax year, please contact the respective agency and obtain this information. 13
State Franchise Tax Board—916-845-4750 IRS:*please contact your local IRS office -Oakland—510-637-2487 -Sacramento—916-974-5225 -San Francisco—415-522-4061 My signature below verifies that I/we have completed the above “New Client Bankruptcy Information Packet” containing 14 pages including this page to the best of my/our knowledge, and all information contained is true, complete and accurate. _________________________________ Client 1 Signature Date
_______________________________ Client 2 Signature Date
_________________________________ Client 1 Print Name
_______________________________ Client 2 Print Name
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